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"Life After Limb Loss: Examining VA Amputee Prosthetics Care"

House Veterans Affairs Committee, Health Subcommittee Hearing

November 20, 2024 (recording here)

HEARING INFORMATION

Witness & Written Testimony (linked) (Panel One):

• Mr. M. Christopher Saslo, DNS, APRN-BC, FAANP: Assistant Under Secretary for Patient Care Services/Chief Nursing Officer, U.S. Department of Veterans Affairs, Veterans Health Administration

• Dr. Joel Scholten: Executive Director, U.S. Department of Veterans Affairs, Veterans Health Administration

• Dr. Ajit Pai: Executive Director, U.S. Department of Veterans Affairs, Veterans Health Administration

• Mr. J. Drew Craig: Design Chief, U.S. Department of Veterans Affairs, Veterans Experience Office

Witnesses & Written Testimony (linked) (Panel Two):

• Mr. Jose Ramos: Vice President of Government and Community Relations, Wounded Warrior Project

• Mr. Matt Brown: U.S. Army Veteran, The Independence Fund

• Ms. Ashlie White: Chief Strategy and Programs Officer, Amputee Coalition

Keywords mentioned:

• Communication breakdowns, unresponsiveness, bureaucratic delays, lack of coordination, frustration, distrust, specialized care, peer support

IN THEIR WORDS

OPENING STATEMENTS FROM THE SUBCOMMITTEE

• Chairwoman Mariannette Miller-Meeks opened the hearing by reviewing the challenges within the VA’s Amputation System of Care (ASoC), particularly concerning prosthetics. She mentioned troubling issues such as improperly canceled prosthetic orders and exaggerated budget shortfalls. The Chairwoman shared a poignant example of a veteran waiting over a year for a prosthetic limb, calling such delays unacceptable and underscoring the devastating mental and physical impacts of these inefficiencies on veterans. She introduced the Veterans SPORT Act (H.R. 9478) to improve access to adaptive prosthetics and committed to ensuring timely, high-quality care for veterans.

• Ranking Member Julia Brownley discussed the importance of comprehensive pre- and post-amputation care for veterans, which includes physical, mental, and prosthetic support. She called for improved in-house VA prosthetic manufacturing capabilities and collaboration with contractors to enhance service delivery. Ranking Member Brownley also praised advancements like 3D printing and telehealth for improving prosthetic accessibility and fit, particularly for women veterans. She welcomed the perspectives of witnesses and spotlighted the value of peer support programs for veterans facing the challenges of limb loss.

SUMMARY OF KEY POINTS (PANEL ONE)

• Dr. M. Christopher Saslo outlined the VA’s interdisciplinary, whole-health approach to amputee care, which focuses on maximizing veterans' functional independence and quality of life. He noted the VA’s significant advancements, including the use of telehealth, 3D printing, and innovative prosthetic technology, such as systems allowing users to feel touch. Dr. Saslo articulated the VA’s commitment to lifelong care and collaboration with the Department of Defense to ensure seamless transitions for service members. He pointed out high patient satisfaction rates and ongoing research to improve prosthetic technology and care delivery.

• Ranking Member Brownley asked Dr. Saslo about the VA’s efforts to address challenges in recruiting female veterans for prosthetic research, given their smaller population. Dr. Saslo explained that the VA uses electronic health records to recruit participants nationally, includes travel funding in research budgets, and implements a Women’s Enhancement Recruitment Toolkit. He highlighted several ongoing and completed studies aimed at addressing the needs of women veterans.

• The Ranking Member followed up by inquiring about female veterans’ satisfaction with prosthetics and additional steps to support them. Dr. Joel Scholten noted that outreach to female veterans is prioritized, partnerships with veterans service organizations (VSOs) are leveraged, and innovations like 3D-printed prosthetics are being developed to address gaps. He then acknowledged that commercially available options remain limited.

• Rep. Greg Murphy expressed frustration with delays in care and asked about the VA’s timeliness in repairing or replacing malfunctioning prosthetics for veterans confined to wheelchairs. Dr. Saslo responded that the average wait time for care is 26 days, slightly below the VA’s 28-day target. Dr. Scholten added that the VA is launching a wheelchair repair contract to improve access and encourages veterans to communicate directly with their care teams for timely appointments.

• Rep. Murphy also asked if the VA monitors complications caused by delays, such as pressure ulcers. Dr. Scholten admitted that he did not have specific data on this issue but acknowledged the importance of quality measures in care delivery.

• Rep. Nikki Budzinski inquired about the VA’s efforts to meet the prosthetic needs of women veterans, particularly those with upper limb loss. Dr. Saslo described VA innovations, including 3D-printed custom foot systems and prosthetic hands designed specifically for women. Dr. Ajit Pai added that the VA is also developing unique projects such as prosthetic sports bras for women veterans.

• Rep. Budzinski then asked how the VA ensures consistent care across facilities, especially in rural areas. Dr. Saslo outlined the VA’s tiered ASoC, which includes mobile prosthetics labs, virtual care, and comprehensive training programs to improve access in underserved regions.

• Rep. Jack Bergman asked whether the VA is more reactive or proactive in its prosthetics care and training. Dr. Saslo emphasized the importance of training prosthetists at national and regional levels and collaborating with the DoD to stay informed on advancements. He noted that the VA updates clinical practice guidelines every five years and participates in DoD training opportunities.

• Rep. Bergman suggested that VA representatives attend the annual modeling and simulation conference in Orlando to explore innovative technologies. Dr. Scholten acknowledged the value of further exploring such opportunities and noted ongoing reviews of emerging evidence.

• Rep. Greg Landsman asked about VA strategies to address gaps in orthotic and prosthetic services, particularly in rural areas. Dr. Saslo highlighted the use of mobile prosthetics labs, in-house fabrication at 89 sites, and virtual care to enhance access. Dr. Pai explained that scanning technology allows facilities without fabrication labs to send specifications to centralized labs, and beneficiary travel supports veterans in reaching appropriate care. When asked how Congress could assist, Dr. Saslo suggested expanding mobile sites and strengthening community partnerships to ensure consistent care.

• Rep. Luttrell questioned how the VA aggregates and shares amputee-related data across facilities, particularly for women veterans. Dr. Pai explained that data from legacy systems are consolidated into national databases, enabling information sharing and direction for clinical programs across all facilities. He acknowledged limitations in tracking data at a granular level, such as specific amputation subtypes or prosthetic advancements.

• Rep. Luttrell also asked whether artificial intelligence could improve the VA’s ability to track prosthetic advancements and communicate updates to veterans. Dr. Saslo admitted that while AI is propelling healthcare advancements, the VA has not yet fully leveraged this technology.

• Rep. David Rouzer raised concerns about veterans feeling like just another number in a bureaucratic system and asked why the VA does not assign a single caretaker to guide veterans through the entire prosthetic process. Dr. Saslo explained that the VA’s ASoC relies on interdisciplinary teams and uses care coordination to assign case managers for high-risk cases. Dr. Pai added that care coordination is crucial and mentioned the VA’s efforts to address gaps when issues arise. Mr. J. Drew Craig noted that post-9/11 combat amputees expressed a need for navigators to guide them through the system. Dr. Saslo then acknowledged the opportunity to refine navigation efforts, likening it to cancer care navigators. 

• Chairwoman Miller-Meeks asked how many veterans had been denied adaptive prosthetics in the past year and what justifications the VA provided for these denials. Dr. Scholten responded that the VA does not track such denials but instead develops individualized care plans based on veterans' medical conditions, comorbidities, and goals. He reported that the VA encourages recreational activities and can provide any FDA-cleared device deemed clinically necessary.

• Chairwoman Miller-Meeks shared a case of a veteran waiting a year for a prosthetic leg due to a backlog at the Nashville VAMC and asked what steps the VA is taking to address such delays. Dr. Pai acknowledged the use of community care and third-party vendors for prosthetic fabrication, noting that about two-thirds of prosthetic limbs are provided by community providers in collaboration with VA clinicians.

• The Chairwoman requested a detailed report on prosthetic backlogs at VA Medical Centers, excluding devices like glasses and hearing aids, by December 20. She also inquired about screening practices for peripheral arterial disease (PAD), given its high mortality rate among veterans. Dr. Saslo explained that the VA uses advanced tools like remote temperature monitoring, sensory mats, and siren socks to identify at-risk veterans. He highlighted reductions in ulcerations, amputations, and hospital admissions as evidence of these efforts' success.

• Finally, Chairwoman Miller-Meeks referenced a 2019 RAND report showing that the U.S. Army prioritizes returning amputees to their highest level of activity, compared to the VA’s focus on community ambulation. She asked whether the VA should adopt the Army’s standard for younger, post-9/11 amputees or if legislation is needed. Dr. Saslo affirmed the VA’s commitment to helping veterans reach their full potential and pointed to adaptive sports programs as a reflection of this goal.

SUMMARY OF KEY POINTS (PANEL TWO)

• Mr. Jose Ramos shared his personal struggles transitioning from DoD to VA care for prosthetics, citing issues such as delays, outdated policies, and lack of familiarity with advanced prosthetic technologies among VA providers. He recommended four steps for improvement: recognizing amputees' unique needs, increasing the hiring of prosthetists, promoting holistic lifestyles for amputees, and expanding innovative programs like mobile prosthetic care. He urged the VA to strive for global leadership in prosthetic care and emphasized the importance of timely and specialized care for amputees.

• Mr. Matt Brown, a veteran who suffered a leg amputation due to bone cancer, shared his frustrating two-year journey navigating the VA prosthetics system. Despite receiving initial community care for his amputation, he described being confined to a wheelchair for months due to delays and miscommunication regarding his prosthetic needs. He recounted specific failures, including the VA's inability to obtain a specialized Quattro socket promptly, repossession of his prosthetic ankle by a vendor due to payment delays, and recurring bureaucratic hurdles. Mr. Brown illustrated the mental health toll of these delays and credited congressional intervention and external advocacy for finally receiving proper care in 2024. He called for a thorough review of the VA’s processes to ensure amputees receive timely, responsive care.

• Ms. Ashlie White detailed the Amputee Coalition’s efforts to support over 5.6 million Americans living with limb loss or limb difference. She praised the VA’s interdisciplinary amputation care model as the gold standard but noted challenges such as healthcare access in rural areas and communication gaps between VA clinics and community providers. Ms. White also expressed concern about workforce shortages in the orthotics and prosthetics field, exacerbated by limited training programs and attrition in master’s programs. She recommended streamlining communication channels, bolstering the workforce pipeline, and improving rural access to care.

• Ranking Member Brownley addressed Mr. Brown, confirming the timeline of his two-year struggle to obtain a proper prosthetic and asking about the challenges he faced. Mr. Brown explained that during this time, he experienced repeated failures with prosthetics, poor communication, and a lack of team care. He shared frustrations about needing a running blade but not receiving training on how to use it, and he described systemic issues such as delayed purchase orders and a lack of understanding of his specific needs. The Ranking Member expressed her appreciation for his testimony and apologized for his poor experience.

• Ranking Member Brownley also asked Ms. White about peer support programs, particularly for women. Ms. White explained that women are underrepresented in their programs but often turn to community support groups. She emphasized the importance of creating tailored support options for female veterans.

• Rep. Luttrell pressed Mr. Brown and Mr. Ramos to identify specific barriers they faced and the names of individuals involved to pinpoint accountability. Mr. Ramos described systemic communication breakdowns and issues with the VA grouping prosthetics with sensory aids like hearing aids, which creates inefficiencies. Mr. Brown outlined basic communication failures, such as years-long issues with phone systems and staff shortages at his local VA. He shared how he had to physically visit the VA to inquire about his prosthetics due to broken communication channels, a situation he described as deeply frustrating and indicative of systemic neglect.

• Rep. Rouzer revisited Mr. Brown's case, asking about the transition of his care from Wilmington to Richmond. Mr. Brown praised the care he received in Richmond, noting the stark contrast to his experience in Wilmington, where staff shortages and mismanagement caused significant delays. He called for accountability and proactive communication. Mr. Ramos added that the VA should model its prosthetic care system after the DoD’s approach, which is more streamlined and responsive, especially for active and younger amputees.

• Chairwoman Miller-Meeks asked Mr. Ramos to compare his experience with DoD and VA prosthetic care. Mr. Ramos detailed how DoD care was significantly faster and more coordinated due to co-located clinics and prosthetists, while VA care required multiple appointments and approvals, leading to delays. The Chairwoman suggested separating prosthetic limb care from other sensory aids within the VA and tailoring care to the unique needs of younger and more active veterans.

• Chairwoman Miller-Meeks then asked Mr. Brown whether the VA engaged him proactively during his cancer diagnosis and amputation process. Mr. Brown explained that he and his wife took proactive steps to prepare, but the VA did not engage him until after his amputation, providing minimal guidance and support.

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